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Topic: Paravertebral Nerve Block and Propofol

Forum: Clinical Trials, Research News, Podcasts, Study Results —

Share your research articles, interpretations and experiences here. Let us know how these studies affect you and your decisions.

Posted on: Aug 25, 2015 06:22PM - edited Jan 7, 2016 10:59AM by Fallleaves

Fallleaves wrote:

I don't want to clutter up Sassy's thread on ketorolac (which may also be of great benefit in reducing recurrence. Her thread can be accessed here: https://community.breastcancer.org/forum/73/topic/... ) , but I think we need to start looking at the kinds of anesthesia we are getting for BC surgery, because it can have a big impact on patient well-being in the short AND long term. Paravertebral nerve block and propofol (which are frequently used together) show promise for not only reducing pain and nausea following surgery, and reducing hospital stays, but also reducing the use of opioids during and after surgery, and most importantly, reducing recurrence and mortality. Geewhiz posted a link to one of the most important studies on the ketorolac thread and I've included it below (Exadaktylos, 2006). Some of these studies compare Paravertebral nerve block with general anesthesia, some use it in addition to general anesthesia. I've only listed studies that show a benefit for nerve block, but I have run across a few that show no advantage over general anesthesia alone. However, NO studies have shown it is detrimental to patients, unlike opioids, which may suppress the immune system and actually promote cancer growth. I have also added a study on pectoral nerve block (with general anesthesia) that did not look at its effect on recurrence, but did find it reduced perioperative consumption of fentanyl and morphine, and reduced postsurgical nausea, vomiting, and length of hospital stay.

Paravertebral Nerve Block and Pectoral Nerve Block (regional anesthesia)

"Use of paravertebral block anesthesia in the surgical management of breast cancer: experience in 156 cases."

Twenty percent of patients in the paravertebral group required medication for nausea and vomiting during their hospital stay compared with 39% in the general anesthesia group. Narcotic analgesia was required in 98% of general anesthesia patients, as opposed to 25% of patients undergoing paravertebral block. Ninety-six percent of patients having paravertebral block anesthesia were discharged within the day of surgery, compared with 76% of patients who had a general anesthetic.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1191303/
(Coveney, 1998)



"Paravertebral block: an alternative to general anesthesia in breast cancer surgery."

"Postoperative narcotics were given to 80.8 and 93 per cent of PVB and GA patients, respectively (P < 0.01), after an average of 216 and 122 minutes from the end of surgery (P = 0.028). The PVB group received 6.2 narcotic units compared with 10.1 in the GA group (P = 0.04). Postoperative nausea and vomiting was present in 16.8 and 24 per cent of patients in the PVB and GA groups, respectively (P = 0.12). A diet was tolerated on the same day of surgery by 98.4 and 82 per cent of PVB and GA patients, respectively (P < 0.01). The complication rate of PVB was 1.8 per cent. PVB resulted in better postoperative pain control and earlier resumption of diet compared with GA. The good success rate and low complication rate of PVB make it well suited for breast cancer surgery and can eliminate the need for GA in patients with serious comorbidities."

http://www.ncbi.nlm.nih.gov/pubmed/12678477
(Najarian, 2003)



"Nerve-stimulator guided paravertebral blockade vs. general anesthesia for breast cancer: a prospective randomized trial."

"...the need for supplemental opioid administration during the first 3 days postoperatively, (was) significantly lower in patients handled with para-vertebral nerve blockade compared to patients receiving general anaesthesia (P < 0.05). The number of patients free from nausea and vomiting after operation was significantly higher in the paravertebral nerve blockade group (93%) compared to the general anaesthesia group (67%) (P < 0.05). The use of paravertebral nerve blockade was also associated with a significantly shorter hospital stay (median 1 day) compared to general anaesthesia (2 days) (P < 0.01). Both the performance of the block and the intraoperative conditions was well accepted by the vast majority of patients treated by paravertebral nerve blockade (97%).

http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=316976&fileId=S0265021503001443
(Naja, 2003)



"Can anesthestic technique for primary breast cancer surgery affect recurrence or metastasis?"

Fifty patients had surgery with paravertebral anesthesia and analgesia combined with general anesthesia, and 79 patients had general anesthesia combined with postoperative morphine analgesia..Recurrence- and metastasis-free survival was 94% (95% confidence interval, 87-100%) and 82% (74-91%) at 24 months and 94% (87-100%) and 77% (68-87%) at 36 months in the paravertebral and general anesthesia patients, respectively (P = 0.012).

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1615712/
(Exadaktylos, 2006)


"Improved postoperative pain control using thoracic paravertebral block for breast operations."

"Patients were subdivided into three groups: Group A-segmental mastectomy only (n = 89), Group B-segmental mastectomy and sentinel node surgery (n = 111) and Group C-more extensive breast surgery (n = 113). Immediately after surgery there was a statistically significant difference in the number of patients reporting pain between PVB patients and those without PVB. At all time points up until the morning after surgery PVB patients were significantly less likely to report pain than controls. Patients in Group C who received PVB were significantly less likely to require overnight stay. The average immediate pain scores were significantly lower in PVB patients than controls in both Group B and Group C and approached significance in Group A. PVB in breast surgical patients provided improved postoperative pain control. Pain relief was improved immediately postoperatively and this effect continued to the next day after surgery. PVB significantly decreased the proportion of patients that required overnight hospitalization after major breast operations and therefore may decrease cost associated with breast surgery."

http://www.ncbi.nlm.nih.gov/pubmed/19624418
(2009)



"Efficacy and safety of paravertebral blocks in breast surgery: a meta-analysis of randomized controlled trials."

"Fifteen randomized controlled trials (published between 1999 and 2009) including 877 patients met the inclusion criteria. There was a significant difference in worst postoperative pain scores between PVB and general anaesthesia (GA) at <2 h (MD: -2.68; 95% CI: -3.33 to -2.02; P<0.00001), 2-24 h (MD: -2.34; 95% CI: -2.42 to -1.12; P<0.00001), and 24-48 h (MD: -1.75; 95% CI: -3.19 to 0.31; P=0.02). Accordingly, lower pain scores were observed for combined PVB with GA compared with GA alone for <2 h (MD: -1.87; 95% CI: -2.53 to -1.21; P<0.00001), 2-24 h (MD: -2.21; 95% CI: -3.07 to -1.35; P<0.00001), and 24-48 h (MD: -1.80; 95% CI: -2.92 to 0.68; P=0.002). The RR for the reported adverse events (e.g. pneumothorax) was low."

"There is considerable evidence that PVB in addition to GA or alone provide a better postoperative pain control with little adverse effects compared with other analgesic treatment strategies."

http://www.ncbi.nlm.nih.gov/pubmed/20947592
(Scnabel, 2010)


"The effect on improvement of recovery and pain scores of paravertebral block immediately before breast surgery."

"Pain scores at rest were significantly lower in the GA+PVB group at all designated time points [1 hour (p<0.0001), 6 hours (p<0.0001), and on midmorning of POD1 (p=0.041)]. Pain scores with movements was also significantly lower at all time points in the GA+PVB group (1 hour, p<0.0001; 6 hours, p<0.0001; midmorning of POD1, p=0.0012). Areal distribution of pain at rest and with movement was wider in the GA group 1 hour and 6 hours postoperately but was identical to that of GA+ PVB group on the mid-morning of POD1 [1 hour postoperatively at rest (p<0.0001), with movement (p<0.0001); 6 hours postoperatively at rest (p=0.0018), with movement (p=0.0048)]. The QoR scores were significantly higher in the GA+PVB group at 6 hours (p<0.0001) and on midmorning of POD1 (p=0.0079). The incidences of postoperative nausea and vomiting were significantly lower in the GA+PVB group (p=0.0004). Doses of postoperative analgesics and narcotics were significantly less in the GA+PVB group (p<0.0001 and p=0.001, respectively). Time to first request for analgesics was significantly longer in the GA+PVB group (p=0.0002)."

http://www.ncbi.nlm.nih.gov/pubmed/21982169
(Li, 2011)



"Paravertebral block can attenuate cytokine response when it replaces general anesthesia for cancer breast surgeries."

"Replacing GA with PVB can attenuate cytokines response to cancer breast surgeries." (Proinflammatory cytokines can drive cancer growth and spread.)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3858685/
(Sultan, 2013)


"Anesthesia technique may reduce breast cancer recurrence, death." (article, not study)

During cancer surgery, tumor cells released into the bloodstream can transfer from the original tumor area and implant in lymph nodes and other organs far from the primary tumor, according to Dr. Carlsson. The human immune system plays a major role in fighting these runaway cells; however, surgery and anesthesia weaken the immune system.

In the study, a follow-up to a randomized, double-blinded study of paravertebral blocks (regional anesthesia nerve blocks) in 77 patients who had breast cancer surgery, the patients were divided into two groups, both having general anesthesia. In addition, the first group received a regional nerve block via four to six injections of local anesthetic. The second group received injections of saline. After six years, these patients' medical records were reviewed for death or cancer recurrence.

The study found that the death rate was significantly lower in the group who received the nerve block with general anesthesia. Ten percent of patients who received the nerve block and general anesthesia died compared to 32 percent of patients who received the placebo. Additionally, the rate of cancer recurrence was significantly less for the nerve block and general anesthesia group as compared to the placebo group: 13 percent had a recurrence while 37 percent of the placebo group's cancer returned. The nerve block and general anesthesia group also took significantly fewer opioids than the placebo group: an average of 45 mg of morphine compared to the patients with cancer recurrence who took an average of 58 mg of morphine.

http://www.sciencedaily.com/releases/2013/10/131015191057.htm
(Carlsson, 2013)



"Anesthetic technique improves quality of recovery for women having breast cancer surgery." (link to study at end of article)

Anesthesiologists using a technique similar to a dental freeze can improve the quality of recovery and decrease recovery time for breast cancer surgery patients, according to a new study. The paravertebral block technique uses ultrasound to precisely guide a needle to intercostal nerves reaching the breast and deliver local anesthetic to freeze these nerves.

http://www.sciencedaily.com/releases/2014/03/14031...

(Abdallah, 2014)


"Thoracic paravertebral regional anesthesia improves analgesia after breast cancer surgery: a controlled randomized multicentre clinical trial"

Meta-analysis, including the current study, estimated a reduction in worst pain of 2.3 points (95% CI: 1.8 to 2.8) on a 0-10 scale and a 72% reduction (95% CI: 42 to 87) in mean opioid consumption in the immediate two postoperative hours for PPA vs SOA.

http://www.ncbi.nlm.nih.gov/pubmed/25480319

(Wu, 2015)


"Pectoral nerves I and II blocks in multimodal analgesia for breast cancer surgery: a randomized clinical trial."

"...postoperative morphine consumption in the Pecs group was lower in the first 12 hours after surgery than in the control group. In addition, statistically significant lower intraoperative fentanyl consumption was observed in the Pecs group than in the control group. In the postanesthesia care unit, nausea and vomiting as well as sedation scores were lower in the Pecs group compared with the control group. Overall, postanesthesia care unit and hospital stays were shorter in the Pecs group than in the control group."

"The combined Pecs I and II block is a simple, easy-to-learn technique that produces good analgesia for radical breast surgery."

http://www.ncbi.nlm.nih.gov/pubmed/25376971

(Bashandy, 2015)




Propofol

"Suppression of natural killer cell activity and promotion of tumor metastasis by ketamine, thiopental, and halothane, but not by propofol: mediating mechanisms and prophylactic measures."

http://www.ncbi.nlm.nih.gov/pubmed/14570648

(Melamed, 2003)


"Anesthesia in patients with cancer disorders"

Accumulated basic and clinical data suggest that total intravenous anesthesia with propofol, cyclooxygenase antagonists, and regional anesthesia can decrease negative consequences associated with perioperative immunosuppression. Volatile anesthesia, systemic morphine administration, unnecessary blood transfusions, intraoperative hypoxia, hypotension, hypothermia, and hyperglycemia should be avoided.
http://www.ncbi.nlm.nih.gov/pubmed/22450698
(Kurosawa, 2012)


"Impact of anesthesia on cancer recurrence"

"Anesthetics and analgesics used during the perioperative period may modulate the innate and adaptive immune system, inflammation and angiogenesis, and have a direct effect on cancer cells that could ultimately modify oncological outcomes. For instance,volatile anesthetics and opioid analgesics have shown predominantly pro-tumor effects, while propofol, non-steroid anti-inflammatory drugs have mostly anticancer effects
http://www.ncbi.nlm.nih.gov/pubmed/26026503

(Lee, 2015)


"Effect of anaesthetic technique on immune cell infiltration in breast cancer: a follow-up pilot analysis of a prospective, randomised, investigator-masked study."

"PPA (propofol-paravertebral anesthestic) induces increased levels of NK and T helper cell infiltration into breast cancer tissue compared with GA (general anesthesia) but not T suppressor cells or macro phages. This is consistent with the hypothesis that the anaesthetic technique may affect perioperative immune function conducive to resisting breast cancer recurrence and metastasis."

http://www.ncbi.nlm.nih.gov/pubmed/25750280

(Desmond, 2015)


"Perioperative propofol-paravertebral anesthesia decreases the metastasis and progression of breast cancer."

This is just an abstract---I couldn't find free access to the whole paper. It's a review article.

http://www.ncbi.nlm.nih.gov/pubmed/26383520

(Chen, 2015)


Links to other related threads:

NSAIDS and breast cancer, by 123JustMe (Sept, 2015): https://community.breastcancer.org/forum/73/topic/...

Anesthesia and cancer recurrence (general review articles), by fallleaves (Sept.,2015): https://community.breastcancer.org/forum/73/topic/...

Effects of opioids on cancer progression, by fallleaves (Sept., 2015): https://community.breastcancer.org/forum/73/topic/...




Dx 7/5/2013, IDC, 2cm, Stage I, Grade 2, 0/2 nodes, ER+/PR+, HER2- Surgery 8/20/2013 Lumpectomy: Right
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Aug 26, 2015 01:53PM flannelette wrote:

WOW! this is really interesting! I was given the choice of having the "24 hour pain" block in 2008 while lying on the gurney waiting for my MX. A young dr bounced in, said I was lucky I had him for my anesthetist that day as he'd just come from a pain control learning session for MXs at a major hospital and not all anesthetists could do this. He highly recommended it and said he'd be back to hear my decision. Lucky me. I'd not had a clue this even existed.

So I had it, sitting up, felt like a painless corkscrew going into my back. I was already hooked up to something good in the IV & felt like I'd had a few vodkas & could do the operation myself & quite enjoyed looking around at the operating room - nice & bright. then the general anesthetic & seemed like in a nano second I was awake in the recovery room in fine form. No trace of nausea or pain. By this time I'd not eaten in a long time so up to my overnight room where I wolfed down big supper. No pain. read newspapers. great mood. Nurse came at midnight to ask if I wanted - morphine? - I said yes, guess so - but wasn't in any pain at all. Went home next day at noon.

I never, ever, had one bit of pain. I mean, I never took so much as a tylenol after my MX. I'm 7 years out from surgery.

I cannot say how easy my MX experience was, or how quickly I healed. I never even knew for a few years what the 24 "pain block" was, though it interested me hugely. But i thank my lucky stars I had it, and am very excited to read these studies!

Thanks so much for posting them - I have always been eager to find more info (though not in any really applied way) about my super easy - and even happy, MX experience, crazy as that sounds. And reading the long-term outcomes is icing on the cake.


Dx 7/2008, IDC, 6cm+, Stage IIB, 0/6 nodes, ER+/PR+, HER2- Surgery 7/29/2008 Mastectomy: Left Chemotherapy 9/30/2008 CEF Radiation Therapy 1/9/2009 Hormonal Therapy 2/14/2009 Arimidex (anastrozole) Surgery 7/19/2012 Lymph node removal: Right, Underarm/Axillary Dx 7/20/2012, 0/6 nodes
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Sep 21, 2015 11:53AM Fallleaves wrote:

Hi Flannelette,

It was great reading about your personal experience! (Sorry it took me so long to respond, I've been away from the boards for a few weeks) Sounds like the nerve block worked wonders for you! With all the good studies that are piling up, I really don't understand why it isn't being done more often. Well, maybe when more BC patients read about positive experiences like yours, they'll start telling their anesthesiologists, "I'll have what she's having!"

Dx 7/5/2013, IDC, 2cm, Stage I, Grade 2, 0/2 nodes, ER+/PR+, HER2- Surgery 8/20/2013 Lumpectomy: Right
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Sep 21, 2015 05:07PM solfeo wrote:

At our initial meeting I asked the surgeon about Propofol but she reacted like that was out of the question. "That is a sedative," in her exact words. She seems to be OK with the paravertebral block, so I guess I need the anesthesiologist on board to make the combination happen with Propofol. Have no idea who that will even be.

I'm so overwhelmed by information right now I'm ready to just lie down and let them have their way with me. (just kidding, I persevere). I'm sure it's going to put me into PITA territory if I'm not already there, but I wonder what my chances are of scheduling a meeting with the anesthesiologist in advance of the surgery day?

Oncotype 13 Dx 7/31/2015, IDC, Right, 3cm, Stage IIA, Grade 1, 0/2 nodes, ER+/PR+, HER2- (FISH) Surgery 10/7/2015 Lymph node removal: Right, Sentinel; Mastectomy: Left, Right Hormonal Therapy 11/16/2015 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Sep 22, 2015 07:23AM Englishmummy wrote:

I had a bilateral paravertebral block for my NSBMX in June, with ON Q pain balls - which lasted 3 days after my surgery and intercostal nerve blocks. They put the On Q balls on, I walked to the operating room, laid on the table and like Flannelette said "in a nano second" it was over; I was back - crying because my nodes were clear.

Solfeo: I got 45 mins with the anesthesiologist prior to the surgery as he went through everything - but I think talking to yours directly prior to your surgery is a great idea, I was very blind on that part.

 After surgery I took 1 oxycontin and went on to Tylenol, I had no pain at all, it really was amazing. I was up and about around 2 hours after I came round and the nurses kept coming in to see what my pain level was, they could not believe it when I said I was a "1"  or "2". I ate, was in a pretty good mood, (got voted the 'nicest patient ever'), ate some more, read, chatted with my hubby, called my children, slept. The PS, surgeon or anesthesiologist could not believe how well I came out of it - they did not say, but my hubby and I both agree that it was likely the first, or nearly first time they had combined it all in one surgery. I was up and dressed before they came to see me the next day. No headache, nausea, or pain. I had a Propofol and general anesthetic (can't remember what it was) but no narcotics as I was told that Propofol is a short term analgesic which leads you in to the main General, as BMX with recon is a longer surgery - although nowhere near the length of Flap surgery. I am having Propofol for my exchange on the 9th, again, no narcotics. On-Q pain balls ROCK, why they don't use them for everyone, I have no idea. 3 months out, I am healing very well, having had no real problems at all.

I feel like the stars aligned for me in my surgical adventure, I only wish they would for everyone.

 

 

Dx 5/22/2015, IDC, Right, 2cm, Grade 2, 0/5 nodes, ER+/PR+, HER2- (FISH) Dx 5/22/2015, IDC: Tubular, Left, 1cm, Grade 1, 0/1 nodes, ER+/PR+, HER2- (FISH) Surgery 6/10/2015 Mastectomy: Left, Right; Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Hormonal Therapy Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Sep 22, 2015 08:37AM SummerAngel wrote:

I had a paravertebral block before my BMX. The anesthesiologist told me how it worked and said I might not remember any of it after the surgery. I told him I'm sure I would, I always do (I did). He had an unexperienced assistant do it, so the entire time I kept hearing him telling her things like, "No, twist it the other way" - not exactly encouraging but it wasn't really bothering me because of the sedative they had put into my IV. Then when they were wheeling me into the operating room the anesthesiologist said, "I have decided that you are a very calm, stoic patient." Ha. I don't know if the block worked or not. The first night I feel like I needed a "normal" amount of pain meds in my IV, so maybe it wasn't so great for me. I have a high pain tolerance but I also tend to need more pain medication than most to really have it work well for me.

Age at dx: 45. Oncotype, left-side tumor: 9. Right side had multifocal IDC and "extensive" LCIS. Isolated tumor cells in 1 right-side node. Dx 4/3/2015, IDC, Left, 2cm, Stage IIA, Grade 1, 0/3 nodes, ER+/PR+, HER2- (FISH) Dx 4/27/2015, IDC, Right, 1cm, Grade 1, 0/2 nodes, ER+/PR+, HER2- (FISH) Surgery 6/1/2015 Lymph node removal: Sentinel; Mastectomy: Left, Right Surgery 6/1/2015 Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Surgery 8/27/2015 Reconstruction (left): Fat grafting, Silicone implant; Reconstruction (right): Fat grafting, Silicone implant Surgery 12/3/2015 Reconstruction (left): Fat grafting, Nipple reconstruction; Reconstruction (right): Fat grafting, Nipple reconstruction
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Sep 22, 2015 10:29AM Fallleaves wrote:

Hey Solfeo, I don't blame you for being overwhelmed by all the information. There are so many aspects to the BC experience we have to keep track of and make decisions about. I can totally understand the women who tell their doctors, "Just tell me what to do and I'll do it." My Aunt was in that group. I'm more in the PITA camp, myself (as you can probably imagine)!

Anyway, I hope you can run some things by your anesthesiologist before your surgery, if not in person by phone or email. My MIL just had surgery last month and had a good exchange with her anesthesiologist via email. She ended up getting pre-op ketorolac, but not paravertebral nerve block. I think a lot of anesthesiologists are inexperienced with doing nerve blocks, and maybe some are afraid to do them (hers sounded like it). But maybe with the ultrasound guided nerve blocks there will less chance of error and they'll be more willing to do them.

SummerAngel, I think your doctor was right about you being a very calm, stoic patient. Hearing, "No, twist it the other way," probably would have brought me RIGHT out of sedation!

Englishmumm, I've never heard of On-Q pain balls, but they sound lovely!

Dx 7/5/2013, IDC, 2cm, Stage I, Grade 2, 0/2 nodes, ER+/PR+, HER2- Surgery 8/20/2013 Lumpectomy: Right
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Sep 22, 2015 10:51AM SummerAngel wrote:

Fallleaves, your comment made me laugh! I did think to myself (after about the 5th correction to the trainee) that I didn't sign up to be the test dummy!

Age at dx: 45. Oncotype, left-side tumor: 9. Right side had multifocal IDC and "extensive" LCIS. Isolated tumor cells in 1 right-side node. Dx 4/3/2015, IDC, Left, 2cm, Stage IIA, Grade 1, 0/3 nodes, ER+/PR+, HER2- (FISH) Dx 4/27/2015, IDC, Right, 1cm, Grade 1, 0/2 nodes, ER+/PR+, HER2- (FISH) Surgery 6/1/2015 Lymph node removal: Sentinel; Mastectomy: Left, Right Surgery 6/1/2015 Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Surgery 8/27/2015 Reconstruction (left): Fat grafting, Silicone implant; Reconstruction (right): Fat grafting, Silicone implant Surgery 12/3/2015 Reconstruction (left): Fat grafting, Nipple reconstruction; Reconstruction (right): Fat grafting, Nipple reconstruction
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Sep 22, 2015 11:30AM Englishmummy wrote:


They were brill. I wish they could put the On-Q on in my brain probably get more done!!!.....Here's the link, just posting incase anyone is interested http://www.myon-q.com/

Dx 5/22/2015, IDC, Right, 2cm, Grade 2, 0/5 nodes, ER+/PR+, HER2- (FISH) Dx 5/22/2015, IDC: Tubular, Left, 1cm, Grade 1, 0/1 nodes, ER+/PR+, HER2- (FISH) Surgery 6/10/2015 Mastectomy: Left, Right; Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Hormonal Therapy Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Sep 23, 2015 09:59AM Fallleaves wrote:

Thanks for sharing that link, Englishmummy! Very interesting...I wonder if by local anesthesia they're talking lidocaine or something like that? Hope this kind of thing catches on, because it sounds really great for patients. (And I hope they come up with a brain version, too, because I could definitely use a boost up there!)

Dx 7/5/2013, IDC, 2cm, Stage I, Grade 2, 0/2 nodes, ER+/PR+, HER2- Surgery 8/20/2013 Lumpectomy: Right
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Sep 27, 2015 02:58AM - edited Sep 27, 2015 03:03AM by sas-schatzi

Falls, this is wonderful and so is your opiod thread. Nice job. Whew the work, go girl. It'll be a resource for allot of years. Hoping I don't have to use any ;)

Is it okay if I put a link in the Toradol topic box for each? It acts like a transporter link between threads? And your Toradol thread from last year?

Life's journey is not to arrive at the grave safely in a well preserved body, but rather to skid in sideways, totally worn out shouting "holy crap....what a ride".
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Sep 27, 2015 04:17AM Fallleaves wrote:

Hi Sassy,

That would be great if you would put a link to my threads in the Toradol topic box. And I'll delete my posts with those topics in the body of your Toradol thread so it's not cluttering it up. Thanks for the compliment, Sassy, it means a lot coming from you!

Dx 7/5/2013, IDC, 2cm, Stage I, Grade 2, 0/2 nodes, ER+/PR+, HER2- Surgery 8/20/2013 Lumpectomy: Right
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Sep 28, 2015 08:19PM solfeo wrote:

Thanks again for this thread. Made it so easy to print out for my BS. Seeing her Tuesday morning so I should have a solid plan by the time I walk out of there. At least I hope so - the waiting is wearing me out.

Oncotype 13 Dx 7/31/2015, IDC, Right, 3cm, Stage IIA, Grade 1, 0/2 nodes, ER+/PR+, HER2- (FISH) Surgery 10/7/2015 Lymph node removal: Right, Sentinel; Mastectomy: Left, Right Hormonal Therapy 11/16/2015 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Sep 29, 2015 05:16AM Fallleaves wrote:

Solfeo, I'm so glad this thread was helpful to you. Hope your meeting with your BS went well, and you were able to get what you want lined up. I hear you on the waiting---sometimes it's the worst part!

Dx 7/5/2013, IDC, 2cm, Stage I, Grade 2, 0/2 nodes, ER+/PR+, HER2- Surgery 8/20/2013 Lumpectomy: Right
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Sep 29, 2015 03:55PM solfeo wrote:

I am so close to success. The surgeon has agreed to pre-incision injection of Toradol, with Toradol prescription post-op, and minimal opiate use only if needed. She also agreed to the paravertebral block with propofol, and minimal general anesthesia only if necessary. She is going to speak to the anesthesiologist today, and I'm going to meet with him tomorrow, with my clothes on, to discuss it. He could still say no but BS said she thinks she can find someone else in the department to do it.

I'm still going to get the 2nd opinion from another plastic surgeon on Friday, just for information gathering purposes, but unless he says something so brilliant I can't refuse immediate reconstruction, the plan is BMX w/sentinel node biopsy with possible limited ALND next week Wednesday. With delayed reconstruction, if any. BS is still optimistic that my nodes are clear, so hoping to avoid the ALND but we had a nice talk about it and I trust her to be be as conservative as she can based on what she finds once she is in there.

She said her notes are going to be all full of the disclaimers we discussed, but the bottom line is that she is just a really open minded, nice and accommodating kind of surgeon who is willing to give the patient what she wants when it is reasonable to do so. So if anyone wants to know the big secret for talking your surgeon into this stuff - some are going to be flexible and some are not, and you can usually tell pretty quickly which is which. I will note that it was the younger of the two surgeons who was the more flexible one. Don't get me wrong though, I did still have to do quite a bit of persuading, so it's good to go in there prepared with your answers to your surgeon's every possible objection. Thanks to Sassy and Fallleaves for making that part easier.

Cross-posting this in the Toradol thread since it covers both.

Oncotype 13 Dx 7/31/2015, IDC, Right, 3cm, Stage IIA, Grade 1, 0/2 nodes, ER+/PR+, HER2- (FISH) Surgery 10/7/2015 Lymph node removal: Right, Sentinel; Mastectomy: Left, Right Hormonal Therapy 11/16/2015 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Sep 30, 2015 02:04PM solfeo wrote:

Success all around! The Toradol was already approved, so not much more to say about that. I found out I was not being a PITA by requesting the meeting with the anesthesiologist. These pre-surgery meetings are a free service the hospital offers to all patients having surgery. Between the nurse getting the preliminaries done and speaking with the anesthesiologist, they spent a full hour and a half with me. Felt like I really got to know them, and I liked them.

The anesthesiologist sounded pretty excited to be bringing these new procedures to the hospital. He said I will be the first, and probably the first in my entire state to get everything. I believe I will be paving the way for women who come after me to have safer surgeries that do not increase risk of recurrence. Women who wouldn't even know to ask. Makes me feel pretty good. He gratefully accepted Fallleaves research and I believe he is actually going to read it! He said he wanted to do more research and I handed him the packet, "Here, this should get you started."

He was going to let me do it awake with just the block and propofol, but even though my fear of general anesthesia makes me like that idea, I told him just to knock me out so I don't have to lay there for 3 hours. It will be over faster in my perception. They will use the propofol as the general. He's going to shoot for no opiates, but I gave my OK if it turns out to be necessary.

He actually offered me a few different options and all of them sounded good. He himself wants to continue his research over the next week to decide which combination of procedures will give us the best pain control during and after surgery, so I won't know until the morning of surgery exactly what will be done, but it will be a combination of things we already discussed.

He seems to prefer thoracic epidural (I believe he said it is more effective, or lasts longer or something - sorry I can't remember every detail) over paravertebral block for during the surgery - said shouldn't be any problem with the Toradol, but after speaking to one of his colleagues he was thinking that a pectoral block in addition to the epidural might get us everything we want, during and after surgery (he mentioned pain control for 12-30 hours, possibly eliminating the need for opiates completely). They know I am willing to take narcotics if the pain is bad, but they are trying their best to figure out how to make this happen without any. Going out of their way to do so, in fact. I feel pretty good about these people because they really seem to want to make this work as much as I do. You know what I mean? Much better than pushing for something the doctors are not enthusiastic to try, because they might not do their best work.

So I won't be able to tell you exactly what I'm getting until after the surgery, but it will be some combination of block(s) and propofol, with minimal opiates only if necessary.

Gonna cross-post this one to the Toradol thread as well, so it gets seen by everyone who needs it.
Oncotype 13 Dx 7/31/2015, IDC, Right, 3cm, Stage IIA, Grade 1, 0/2 nodes, ER+/PR+, HER2- (FISH) Surgery 10/7/2015 Lymph node removal: Right, Sentinel; Mastectomy: Left, Right Hormonal Therapy 11/16/2015 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Oct 6, 2015 11:48AM - edited Oct 6, 2015 11:48AM by sas-schatzi

Falls this was sent by Dr. Retsky with Doc Gwen Stritter permission. I'm thinking that you may wamt to post on the opiod site too:). I'm thinking it would be very nice to contact her :)

https://www.youtube.com/watch?v=IkKEFF_c0yo

123, same for NSAID thread


Life's journey is not to arrive at the grave safely in a well preserved body, but rather to skid in sideways, totally worn out shouting "holy crap....what a ride".
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Oct 6, 2015 12:43PM 123JustMe wrote:

Posted
Oncotype 15 Surgery 7/23/2015 Lumpectomy: Left; Lymph node removal: Sentinel
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Oct 7, 2015 05:05AM Fallleaves wrote:

Wow, Sassy, that video of Dr. Stritter after her surgery was amazing! She was definitely feeling no pain.

Dx 7/5/2013, IDC, 2cm, Stage I, Grade 2, 0/2 nodes, ER+/PR+, HER2- Surgery 8/20/2013 Lumpectomy: Right
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Nov 3, 2015 08:33AM - edited Nov 3, 2015 08:36AM by Fallleaves

Just found a video on youtube (there are others in the sidebar) that shows how ultrasound guided paravertebral nerve blocks are done, in case anyone is interested: (www.youtube.com/watch?v=l97p0m...


Dx 7/5/2013, IDC, 2cm, Stage I, Grade 2, 0/2 nodes, ER+/PR+, HER2- Surgery 8/20/2013 Lumpectomy: Right
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Dec 28, 2015 05:15AM sas-schatzi wrote:

Bump

Life's journey is not to arrive at the grave safely in a well preserved body, but rather to skid in sideways, totally worn out shouting "holy crap....what a ride".
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Dec 30, 2015 06:48AM sas-schatzi wrote:

Falls thought I would bring the doc letters here too :)


Sep 15, 2015 09:41AM - edited 22 minutes ago by sas-schatzi

Dear Doctor, I request that you give the material I've given you re: The use of Toradol pre-incision serious consideration. I have a vested interest in the prevention of recurrence of breast cancer. Please, do not refuse my request if you have not read this current compelling research. If they're is not an absolute contraindication for the use of Toradol in my case, I request it be used.

--------------------------------

My mantra for medical and nursing information for decades has been " Just when you think you know something look again" I thought I was done searching for an answer yesterday on something else, then I listened, "You don't know enough, look again, you don't know enough look again". That pesky little irritating voice that drives me. I looked again and came upon the Retsky study. This is groundbreaking research as is the Forget study. A leap forward.

There has been ongoing research that is looking at the specific use of Torodal(ketorolac) in the perioperative phase of breast surgery. The initial study was from Belgium. This study is known as the Forget study published in 2010. A particular isolated group of patients that had an unusually low rate of breast cancer recurrence. All had the same breast surgeon and one of two anesthesiologist. The anesthesiologists had a common approach to drugs used for surgery.

Toradol was the common drug given intraoperative.(in surgery---common practice worldwide) Toradol is an NSAID. Your first reaction is that it is contraindicated for surgery. It does have risk, but the risk is outweighed by the benefit. As I stated earlier Toradol is commonly used by Anesthesiologist in the intraoperative phase of surgery.

My suggestion for anyone having surgery is different than my usual that science has to prove that this works. Talk with your surgeon and anesthesiologist pre-op. Ask specifically if they're is any reason that Toradol is contraindicated for use with you. There ARE patients that it should not be given too. With these studies in hand explore the use of Toradol intraoperatively. This drug is so routinely used in surgery, the question is not out of bounds.

Because we in the BC community experience so many surgeries, the pre-op instructions are drilled into our brains. No NSAIDS two weeks before and after. This though is different. The Retsky study had my heart racing and my breathing short. Studies can be difficult to read, but this is too exciting not to drink in every word. Sas-Schatzi

This link is to an article about the Forget et al study, 2010 patient cohort 327

http://www.medscape.com/viewarticle/723293

Forget et all study----this will be/ is a landmark study

http://www.ncbi.nlm.nih.gov/pubmed/20435950

This is a link to Retsky et all study also will be/is a landmark study. It is a broader based analysis. Gives a great description of the inflammatory process and the impact on awakening a distant mets and killing circulating cancer cells and how Toradol influences these.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3831877/

Forget et all study 2014 follow up from the 2010study, cohort 720

http://bja.oxfordjournals.org/content/early/2014/01/23/bja.aet464.full.pdf

The amount and timing recommended by Dr.Patrice Forget is 20 mg preincisional in patients under 60 kg, and 30 mg in patients over 60 kg.

Quotes from Retsky's study

Using Computer Simulation to Analyze Bimodal Relapse Pattern

Based on computer simulation, to explain the 10 month peak we postulated that induction of angiogenesis at the time of surgery provoked sudden exits from dormant avascular phases to active growth and then to detection. That mode is quite sharp and most often seen among premenopausal patients with axillary lymph node involvement (N+). We suggested the remainder of relapses within the first 40 or so months to be surgery-induced growth of previously dormant single malignant cells. We proposed that the broad late peak relapses result from steady stochastic progressions from single dormant malignant cells to avascular micro-metastases and then on to growing deposits with no apparent synchronization to the time of surgery.


Most Important Finding – Early Relapses are the Result of Something that Happens at Surgery

The most important finding of this early work is that something happens at or about the time of surgery to accelerate or induce metastatic activity that results in early relapses. These early relapses comprise over half of all relapses. Surgery-induced angiogenesis of dormant avascular micrometastases and surgery-induced activity of single malignant cells are implicated. Late relapses are apparently not accelerated by surgery but the shallow peak at 5 years occurs as a result of shedding from primary ceasing after primary removal. We have been vigilantly looking for new data with which we can learn more about surgery-induced tumor activity and that perhaps will also lead to improved outcomes. As we describe here, there has been an important development.


An external file that holds a picture, illustration, etc.&amp;#10;Object name is CMC-20-4163_F7.jpg

Forget et al. [40] data from Universite catholique de Louvain in Brussels, Belgium. Relapse hazard is shown for mastectomy patients given ketorolac or not. Data are smoothed as indicated for fig. fig.11.


An external file that holds a picture, illustration, etc.&amp;#10;Object name is CMC-20-4163_F8.jpg

Forget et al. data were updated September 2011 and shown in hazard form but not smoothed as in fig. fig.7.7. Patient data are presented in the table. Patients included in this figure were less than 80 years of age, tumor less than 9 cm diameter and disease free survival greater than 2 months. It can be seen that relapses in months 9 -18 accounted for the major difference between ketorolac and non-ketorolac patients.


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Very often the excuse to not use Toradol is because of concern about postop bleeding. Here are links and abstracts related to actual studies re: Toradol and postop bleeding.

http://www.ncbi.nlm.nih.gov/pubmed/24572864


See comment in PubMed Commons belowPlast Reconstr Surg. 2014 Mar;133(3):741-55. doi: 10.1097/01.prs.0000438459.60474.b5. Ketorolac does not increase perioperative bleeding: a meta-analysis of randomized controlled trials.

Gobble RM1, Hoang HL, Kachniarz B, Orgill DP.

Author information
  • 1Boston, Mass.; and New York, N.Y. From the Harvard Plastic Surgery Combined Residency Program and the Division of Plastic Surgery, Brigham & Women's Hospital, and Harvard Medical School; and New York University Langone Medical Center.
Abstract BACKGROUND:

Postoperative pain control is essential for optimal patient outcomes. Ketorolac is an attractive alternative for achieving pain control postoperatively, but concerns over postoperative bleeding have limited its use.

METHODS:

Computer searches of the MEDLINE, EMBASE, and Cochrane Library databases were performed. Twenty-seven double-blind, randomized, controlled studies were reviewed by two independent investigators for the incidence of adverse events, including postoperative bleeding. Comprehensive meta-analysis software was used to evaluate the differences between ketorolac and control groups.

RESULTS:

Twenty-seven studies with 2314 patients were analyzed. Postoperative bleeding occurred in 33 of 1304 patients (2.5 percent) in the ketorolac group compared with 21 of 1010 (2.1 percent) in the control group (OR, 1.1; 95 percent CI, 0.61 to 2.06; p = 0.72). Adverse events were similar in the groups, 31.7 percent in the control group and 27.9 percent in the ketorolac group (OR, 0.64; 95 percent CI, 0.41 to 1.01; p = 0.06). There was a lower incidence of adverse effects with low-dose ketorolac (OR, 0.49; 95 percent CI, 0.27 to 0.91; p = 0.02). Pain control with ketorolac was superior to controls and equivalent to opioids.

CONCLUSIONS:

This is the first meta-analysis of randomized controlled trials examining whether there is increased postoperative bleeding with ketorolac. Postoperative bleeding was not significantly increased with ketorolac compared with controls, and adverse effects were not statistically different between the groups. Pain control was found to be superior with ketorolac compared with controls. Ketorolac should be considered for postoperative pain control, especially to limit the use of opioid pain medications.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, II.

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http://www.ncbi.nlm.nih.gov/pubmed/11214049

Plast Reconstr Surg. 2001 Feb;107(2):352-5.

Incidence of hematoma associated with ketorolac after TRAM flap breast reconstruction.

Sharma S1, Chang DW, Koutz C, Evans GR, Robb GL, Langstein HN, Kroll SS.

Author information
  • 1Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston 77030, USA.
Abstract

Ketorolac is frequently used as an adjunct for postoperative pain relief, especially by anesthesiologists during the immediate postoperative period. It can be used alone as an analgesic but is more often used to potentiate the actions of narcotics such as morphine or meperidine in an attempt to reduce the total dose and side effects of those drugs. The manufacturer of ketorolac cautions against its use in patients who have a high risk of postoperative bleeding, for fear of increasing the risk of hematoma, but the risk in transverse rectus abdominis musculocutaneous (TRAM) flap patients has never been reported. In a study of 215 patients who had undergone TRAM flap breast reconstruction, it was determined that patients who received intravenous ketorolac (n = 65) as an adjunct to their treatment with morphine administered by use of a patient-controlled analgesia device required less morphine (mean cumulative dose, 1.39 mg/kg) than did patients who did not receive ketorolac (n = 150; mean cumulative dose, 1.75 mg/kg; p = 0.02). There was no increase in the incidence of hematoma in patients who were treated with ketorolac. The data presented in this study suggest that the use of intravenous ketorolac does reduce the need for narcotics administration in patients undergoing TRAM flap breast reconstruction, without significantly increasing the risk of hematoma.

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This study states a three fold increase in hematoma formation after a reduction mammoplasty. if you evaluate the numbers sited in the study in the are small in actual occurrence, but when the phrase "three fold increase" is used in the conclusion of the actual study and then repeated in the abstract, the implication is the numbers are ominous. Another way the authors of the study describe the risk is a 1:16 ratio. When the risk of recurrence is balanced against the hematoma risk, the reduction in recurrence should be weighted in favor of disease free survival


http://www.ncbi.nlm.nih.gov/pubmed/22434401

Retrospective analysis of perioperative ketorolac and postoperative bleeding in reduction mammoplasty.


Abstract PURPOSE:

We conducted a retrospective review following concerns involving a suspected increase in the requirement for surgical re-exploration for hematoma evacuation when ketorolac was administered perioperatively in patients undergoing reduction mammoplasty.

METHODS:

Following ethics approval, a retrospective chart review was conducted of all patients who underwent reduction mammoplasty at our two institutions from the time ketorolac became available in 2004 until surgeons requested its use discontinued in 2007. The data we collected included patient demographics, ketorolac administration, requirement for surgical re-exploration, documented hematoma formation not requiring surgical re-exploration, and excessive bleeding in the perioperative period. Three hundred and seventy-nine patient records were reviewed; 127 of the patients received a single intravenous dose of ketorolac (15 or 30 mg), and 252 of the patients did not receive ketorolac.

RESULTS:

Patients who received ketorolac were at an increased risk of requiring surgical re-exploration for hematoma evacuation (relative risk [RR] = 3.6; 95% confidence interval [CI], 1.4 to 9.6) and hematoma formation not requiring re-exploration (RR = 2.2; 95% CI, 1.3 to 3.6).

CONCLUSIONS:

A single perioperative intravenous dose of ketorolac was associated with a greater than three-fold increase in the likelihood of requirement for surgical hematoma evacuation. Our data suggest that it may be prudent to consider carefully whether the potential risks associated with the use of ketorolac outweigh the potential benefits of using ketorolac in patients undergoing reduction mammoplasty.

//////////////////////////////////////////////////////////////////////////////////////

This is an alternative letter for your Doc and anesthiologist written by Falleaves. At first I was going to delete mine above, but on a reread they're is good info that's not covered in Falls letter. So, I'm leaving mine and adding hers.


Nov 23, 2015 10:26AM - edited Nov 23, 2015 11:47AM by sas-schatzi

Geewhiz, Falls sent me a copy of a letter she wrote to her old doc. I asked that she revise it and post here. I would then erase the old doc letter from page 1 or pg 2. Time is short. Just in case Falls doesn't see your post, I'm reposting part of it. It's really well done :)

Written by Falleaves November 2015

Summarizing the papers I have read, inhaled anesthetics and opioids should be avoided because of their immunosuppressive effects. Opioids have also been implicated in increasing angiogenesis. Total intravenous anesthesia (TIVA) with propofol (which may reduce postoperative nausea) seems to suppress the inflammatory response to surgery. COX-2 inhibitors and NSAIDS, in particular preoperative ketorolac, could also reduce recurrence due to their anti-inflammatory properties, and their reduction of the need for opioids. Paravertebral nerve block (frequently with propofol) may be particularly valuable in reducing inflammatory cascades and preserving immune function, and reducing recurrence. It also provides better pain control than general anesthesia, reducing the need for opioids post surgery. Local anesthetics such as lidocaine and bupivicaine have been shown to cause apoptosis in breast cancer cells, and liposomal bupivacaine can provide good postsurgical analgesia and reduce the need for opioids. Preoperative gabapentin and pregabalin are effective in reducing postoperative pain and opioid use, and is preventive for chronic post surgical pain.

Interestingly, many of the anesthetic choices that appear most likely to reduce recurrence, are also better for overall patient well-being. You may be familiar with enhanced recovery pathways. Johns Hopkins has developed an ERP for colorectal patients: "The goals of the perioperative anesthesiology pathway were achieving superior analgesia, minimizing postoperative nausea and vomiting, facilitating patient recovery, and preserving perioperative immune function...The perioperative anesthetic regimen was tailored to meet the goal of perioperative immune function (in an attempt to decrease surgical site infection and decrease cancer recurrence), in part by minimizing perioperative opioid use." http://www.ncbi.nlm.nih.gov/pubmed/26404073 The Mayo Clinic has created an ERP for breast reconstruction operations, as well. This includes preoperative analgesics and preventive nausea treatment, NSAIDS, liposomal bupivacaine, reduction in opioids post surgery, and resumption of eating and walking soon after surgery. http://newsnetwork.mayoclinic.org/discussion/new-approach-to-breast-reconstruction-surgery-reduces-opioid-painkiller-use-hospital-stays/

It is my thought that if you are talking about a wide range of drugs and techniques that have ALL been tested, approved, and are in wide use, it is wise to favor those that do not promote the growth of cancer. Clearly anesthetics need to be tailored to each patient, but the impact on cancer recurrence should be a factor in the equation. It would be beneficial for breast cancer patients if an enhanced recovery pathway could be developed for them, with particular attention to use of drugs and techniques to reduce the chance of recurrence.

You are a very busy person, and I realize anesthesia is not your area, but as the director of the Breast Center you are in a position to influence every aspect of care. I am linking some of the best studies I have found, and hope that you will share them with your anesthesiologists.

Paravertebral block/Propofol

"Can anesthestic technique for primary breast cancer surgery affect recurrence or metastasis?"

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1615712/

"Efficacy and safety of paravertebral blocks in breast surgery: a meta-analysis of randomized controlled trials."
http://www.ncbi.nlm.nih.gov/pubmed/20947592

"Anesthesia technique may reduce breast cancer recurrence, death."
http://www.sciencedaily.com/releases/2013/10/131015191057.htm

"Thoracic paravertebral regional anesthesia improves analgesia after breast cancer surgery: a controlled randomized multicentre clinical trial"
http://www.ncbi.nlm.nih.gov/pubmed/25480319

Ketorolac

"Intraoperative use of ketorolac or diclofenac is associated with improved disease-free survival and overall survival in conservative breast cancer surgery."
http://www.ncbi.nlm.nih.gov/pubmed/24464611/

"Reduction of Breast Cancer Relapse with Perioperative Non-Steroidal Anti-Inflammatory Drugs: New Findings and a Review"
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3831877/

Local Anesthesia

"Local anesthetics induce apoptosis in breast cancer cells"
http://www.ncbi.nlm.nih.gov/pubmed/24247230

"Evolving Role of Local Anesthestics in Managing Postsurgical Analgesia."
http://www.ncbi.nlm.nih.gov/pubmed/25866297

Gabapentin and Pregabalin
"The Prevention of Chronic Postsurgical Pain Using Gabapentin and Pregabalin: A Combined Systemic Review and Meta-Analysis"
http://www.ncbi.nlm.nih.gov/pubmed/22415535

Review articles on Anesthesia and Cancer

"The effects of anesthesia on tumor progression"
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3601457/#b58

"Are we causing the recurrence-impact of perioperative period on long-term cancer prognosis: Review of currrent evidence and practice"
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4009631/

Life's journey is not to arrive at the grave safely in a well preserved body, but rather to skid in sideways, totally worn out shouting "holy crap....what a ride".
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Jan 7, 2016 08:30AM grandma3X wrote:

I'm having surgery next week and was able to get the BS and PS to agree to a paravertebral block, but when I talked to the BS this week, she thought I wanted it after surgery. She said most patients are too nervous before surgery so they typically don't do it until the patient is in recovery. I told her that I did want it before surgery and she was fine with that. Just wanted to let everyone here know that they should be sure to stipulate that they want the PVB before surgery, otherwise they may find the anesthesiologist unprepared to do it until they are in recovery.

Oncotype score 10. Married 35 years, 2 kids, 3 grands. Marine biologist/biochemist. No BC in my family tree. First diagnosed with multi focal ILC with 2 small tumors seen on MRI. Final pathology showed 1 large tumor measuring 5 cm! Dx 1/13/2016, ILC, Left, 5cm, Stage IIA, Grade 2, 0/1 nodes, ER+/PR+, HER2- Surgery 1/13/2016 Lymph node removal: Sentinel; Mastectomy: Left; Reconstruction (left): Tissue expander placement Surgery 5/18/2016 Prophylactic mastectomy: Right; Reconstruction (right): Tissue expander placement Surgery 10/26/2016 Reconstruction (left): Silicone implant; Reconstruction (right): Silicone implant Surgery 10/11/2017 Reconstruction (left): Fat grafting; Reconstruction (right): Fat grafting Surgery 10/11/2017 Prophylactic ovary removal Hormonal Therapy Femara (letrozole)
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Jan 7, 2016 09:03AM Fallleaves wrote:

Ahh, good point, Grandma3x---thanks for sharing that! Glad your doctors are so open to your request. Hope you breeze through surgery next week!

Dx 7/5/2013, IDC, 2cm, Stage I, Grade 2, 0/2 nodes, ER+/PR+, HER2- Surgery 8/20/2013 Lumpectomy: Right
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Jan 7, 2016 09:03AM solfeo wrote:

At my request I had the propofol as my only general anesthesia, which my surgeon and anesthesiologist were happy about because they could administer the block while I was knocked out. I had two humongous bruises with big knots underneath from the block that didn't go away for over a month, and I don't think I would have wanted to do that awake. Maybe ask about propofol. The after effects were so minimal I was able to walk out of the hospital 4 hours after my BMX.

Oncotype 13 Dx 7/31/2015, IDC, Right, 3cm, Stage IIA, Grade 1, 0/2 nodes, ER+/PR+, HER2- (FISH) Surgery 10/7/2015 Lymph node removal: Right, Sentinel; Mastectomy: Left, Right Hormonal Therapy 11/16/2015 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Jan 7, 2016 09:11AM solfeo wrote:

Oh nevermind - I remember now that they said I would have had to be awake for a paravertebral block. I had a pectoral block instead because there was no one at that hospital with a lot of experience doing PVB. But the pectoral block was apparently plenty effective because I couldn't feel a thing until it started to wear off the next day. The doctors saw having me unconscious for the block as a benefit of pectoral block over PVB, and they said that is what they plan to offer to others in the future.

Oncotype 13 Dx 7/31/2015, IDC, Right, 3cm, Stage IIA, Grade 1, 0/2 nodes, ER+/PR+, HER2- (FISH) Surgery 10/7/2015 Lymph node removal: Right, Sentinel; Mastectomy: Left, Right Hormonal Therapy 11/16/2015 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Jan 7, 2016 10:47AM Fallleaves wrote:

Thanks for jogging my memory, Solfeo! I ran across this study about pectoral blocks, which didn't look at effect on recurrence, but did indicate use of pectoral block lowered intraoperative fentanyl consumption, and reduced postoperative nausea, vomiting, morphine consumption and hospital stay in modified radical mastectomy patients. http://www.ncbi.nlm.nih.gov/pubmed/25376971 I'll post it in the box, too. It's good for everyone to know all the options.

Btw, I think you can combine PVB with general anesthesia. It looks like that's what they did in the Exadaktylos study from 2006 (in box above). I'd be willing to bet your pec. block with general anesthesia will have reduction in recurrence similar to what was found in that study!

Dx 7/5/2013, IDC, 2cm, Stage I, Grade 2, 0/2 nodes, ER+/PR+, HER2- Surgery 8/20/2013 Lumpectomy: Right
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Jan 7, 2016 11:53AM solfeo wrote:

Yes they can be combined, but they told me you need to be awake to give you the PVB. Since I wasn't going to get one I didn't ask too many questions, but my assumption was that they needed you to have control of your body for some reason. Maybe you have to sit up? Then they give you the propofol after it's working. That may not be true but that is what they said.

I assumed the pectoral block would have the same benefits as PVB for recurrence reduction. I'm so cynical about studies, now I want to say who the hell knows.

Another thing I'm remembering late is that the BS said she would be offering the pectoral block and propofol only to women not having immediate reconstruction. I asked her why and she said plastic surgeons might have concerns about the drug in the block leaking out since they need to go between the muscles. She said she personally did not think that should be an issue, but I guess that's the possible caution and she thought PS's might balk. Reminds me of how so many surgeons won't use toradol when in reality their concerns are probably unfounded. I don't think anyone really knows. So if I have reconstruction I might have to find someone who can do the PVB instead. I haven't talked to my PS about it yet because I'm still not sure I'm going to do recon.

Oncotype 13 Dx 7/31/2015, IDC, Right, 3cm, Stage IIA, Grade 1, 0/2 nodes, ER+/PR+, HER2- (FISH) Surgery 10/7/2015 Lymph node removal: Right, Sentinel; Mastectomy: Left, Right Hormonal Therapy 11/16/2015 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Jan 7, 2016 12:02PM solfeo wrote:

Should probably clarify: The concern about the block drug leaking out during recon only applies to pec block, not PVB, because of the location.

Oncotype 13 Dx 7/31/2015, IDC, Right, 3cm, Stage IIA, Grade 1, 0/2 nodes, ER+/PR+, HER2- (FISH) Surgery 10/7/2015 Lymph node removal: Right, Sentinel; Mastectomy: Left, Right Hormonal Therapy 11/16/2015 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Jan 7, 2016 01:57PM sas-schatzi wrote:

Solfeo send a Pm to Dr. Forget, and ask if he would come here and look. He will answer what he can I think.

Life's journey is not to arrive at the grave safely in a well preserved body, but rather to skid in sideways, totally worn out shouting "holy crap....what a ride".
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Jan 8, 2016 06:32AM peacestrength wrote:

Thanks for clarifying, solfeo.

2013, IDC Stage 3a

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